Motivation and emotion/Book/2017/Stigma and emotion

Overview
Emotions are adaptive features of human nature which are triggered by external events. Emotional states guide and drive behaviour and encourage or discourage interpersonal interactions. While there are substantial differences between individuals' emotional characteristics, certain situations have been shown to stimulate specific emotional responses. For example, social exclusion can be linked to negative emotional states associated with decreased social support and low self-esteem. Thereby adversely influencing physical and psychological well-being. Psychological and sociological research has been conducted into individuals' emotional responses to social exclusion.

Social rejection based upon characteristics or traits of an individual or group is known as Social Stigma. Stigmatisation can occur both explicitly and implicitly. There are many theories and explanations of this phenomenon and individuals' and groups' responses to it. Labelling theory and Social Identity theory draw on psychologists’ interpretation of social interactions. In conjunction with theories exploring the process of stigmatisation, psychological theories of emotion including cognitive appraisal theory and self-fulfilling prophecy can be applied to the concept of stigma. This chapter examines the emotional impact of stigmatisation on those with mental illness and obesity from theoretical and research perspectives.

Distinctions
In order to understand stigma, it is important to distinguish between the following concepts:

Stereotypes are broadly recognised characteristics or behaviours, either positive or negative, which are thought to be representative of the whole population or group. Despite the existence of a stereotype, an individual may not necessarily act upon it (Corrigan & Penn, 2015). Stigma is the social disapproval and devaluation of an individual based upon traits they may possess. According to Goffman, stigma discredits an individual, reducing them "from a whole and usual person to a tainted, discounted one" (Major & O'Brien, 2005). Prejudice is based on a commonly accepted, negative, stereotypical view of a person or group. In this instance, a stereotype is acknowledged and actively guides behaviour towards the group. Discrimination is the action of prejudice, specifically targeting the individual or group. Discrimination commonly causes physical or psychological harm.

Evolutionary theory
Evolutionary theory was originally developed by Charles Darwin to explain animal survival and adaptation. It can also be applied to human behaviour. Some implicit cognitive thought structures relating to basic survival behaviours, may drive stigma and social exclusion. As belonging to a group was central to survival in early human evolution, an individual who was a liability, in terms of hunting, protection or reproduction, may well have been excluded as it is in the group's best interest for survival. (Bellisari, 2008).

Durkheim's theory of stigma
Emile Durkheim is known as the father of sociology. His work, which explored the nature of social stigmatisation, has influenced and encouraged the development of many other theoretical perspectives. Durkheim’s theory considers the concept of social deviance which occurs when the behaviour of an individual or group fails to meet the societal norms of interpersonal interactions (cited in Scambler, 2009). Such deviant behaviour can lead to the expulsion of individuals from the group. As belonging is an innate feature of human nature (Baumeister & Leary, 1995), social exclusion can cause serious trauma as individuals or groups are stripped of their positive, group identity and stigmatised which may in turn lead to discrimination and ostracism.

Goffman's theory of stigma
Erving Goffman elaborated on Durkheim’s theory, describing three distinct types of stigma: stigma of character traits, physical stigma and stigma of group identity (Goffman, 1964).

Labelling theory
Becker's labelling theory (1963) states that once a group or individual has been labelled as deviant, their behaviour and implicit self-concept will be modified to fit that label. Such individuals or groups will become socially excluded from the wider society in some aspects and drawn into alternate social groups. As social inclusion towards the deviant group increases, the gap between "us" and "them" widens.

Social identity theory


Developed by Henri Tajfel (1979), social identity theory emphasises the importance of social "in-groups" and "out-groups". Most individuals exhibit characteristics which allow them to fit into the "in-group". Those who do not, fall into the ‘out-group’. To compensate, these "out-groups" may stand together, increasing social support which contributes to positive emotional outcomes.

Schemas
A Schema in an important to understand when looking at human behaviour, social interactions and emotional responses. They describe the cognitive processes which allow for quick classification of objects, people and external environments (Baldwin, 1992). Schemas expand and change depending on one’s experiences. While schemas are extremely useful, when applied to people, they can lead to stereotyping, stigma, prejudice and discrimination and stigma.

Theories of emotion
While the previous theories explored the processes relating to stigma, those following can be applied to explain the emotional reactions to stigmatisation and the role of self-concept.

Self-Schemas
Self-Schemas are derived from the broader concept of social schemas (Markus, 1977). They refer to the internal cognitions and concepts which form "the self". Stimuli relating to the self are interpreted and processed depending on one's self schema. Negative self-schemas are associated with negative affect and may lead to aggression, depression and/or withdrawal as information regarding the self is interpreted negatively than it should. Both external and internal environments impact upon these cognitions. Identification as deviant or as part of an ‘out-group’ may also lead an individual to develop negative self-schemas. This is a cyclical process with the negative emotions increasing the deviant behaviour and reinforcing undesirable, isolating social outcomes.

Cognitive appraisal theory


The Appraisal Theory states that individuals' emotional responses to a situation may differ due to the way in which they are cognitively interpreted. In the case of social stigmatisation, the emotional effects may differ depending on the individual's interpretation of the situation (Lazarus, 1991). This theory is especially relevant when exploring the concept of stigma, as those who are more frequently exposed to stigmatisation or have a less positive affect may appraise and therefore respond to it differently from those who have never experienced it before or who have a more positive outlook. Lazurus' concept of stress appraisal states that high situational stress coupled with physiological responses lead to an aversive cognitive state. This suggests that increased levels of stress may impact upon coping strategies and given that social exclusion or negative responses from others can cause stress, it follows that stigmatisation can impact negatively on an individual's emotional state.

Self-fulfilling prophecy
Robert. K. Merton's (1948) Self-fulfilling prophecy refers to the tendency to change behaviour as a result of internalised concepts of the self. With relation to stigma, this theory can be applied to show that behaviour exhibited by a member or members of a particular stigmatised group, influences the attitudes, views and stereotypes of non-members toward the group as a whole. Meaning, the more people identify with these labels, the more likely their behaviour will reflect that label. Thus, the beliefs people hold towards stigmatised members of society will elicit self-schemas and behaviour change consistent with those beliefs; confirming the stereotype and reinforcing the cycle. The emotional impact of this varies depending on the nature of the attitudes and behaviours being perpetuated.

It can be argued that these theories inform and direct other theoretical perspectives and to explain the impact of stigmatisation on emotion.

Mental health disorders
‘Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.’ (World Health Organisation, 2014) Mental health disorders then, are conditions impinge of these characteristics.

History


Social stigmatisation has long been a part of the History of mental disorders. Ancient Greeks understood illness as imbalances in bodily fluids leading to changes in mood. The rise of religion established the belief that illnesses, both physical and psychological, were curses from the devil or evil spirits imposed as punishment for sins. While society has moved forward substantially, fear and misunderstandings persist around these illnesses (Hinshaw, 2010).The scientific revolution advanced understanding of the human body and medicine. However, limited understanding of the brain and mental disorders, remained with treatment sometimes more harmful than helpful. Psychiatric hospitals separated the mentally ill from the rest of the population. Terrible conditions were common and effective treatments rare. Dehumanisation followed with individuals being viewed as beasts and animals. (Hinshaw, 2010). Historical misunderstandings, fears and treatment have contributed to the stereotypes associated with mental illnesses which are still impacting on society’s behaviour to this day. More recently, advancements in medicine and psychiatry have contributed to the development of more effective, safe treatments for psychopathological disorders. Between the 1970s and the 1990s, many highly significant experimental techniques were developed, allowing more dynamic and appropriate treatment strategies (Australian Psychological Society, 2017). In 1992, the Australian government developed new legislation regarding the treatment of the mentally ill. In 1993, the human rights commission addressed the neglect and abuse of those affected by mental illness. While this was a positive step forward in improving conditions, the stigma surrounding metal illness remained (Groom, Hickie & Davenport, 2003).

Emotional effect
Many of the theories discussed focus on the societal tendency to categorise and respond to individuals based upon their characteristics or traits. In terms of mental illness, stigma and social exclusion occur as a result of a negative evaluation of the individual who may be characterised as a rebellious free spirit, a homicidal maniac or to have a childlike perception of the world (Corrigan & Penn, 2015) or  ‘unpredictable, dangerous and untrustworthy’ (Kurzban & Leary, 2001). This view derives in part from historical perspectives and lack of effective treatments and partly from negatively evaluated social interactions. Goffman highlighted that predictable behaviour is necessary for successful social interactions, and when an individual’s behaviour is unpredictable, negative assumptions may be made and stereotypes formed. These contribute to fear and suspicion; shaping cognitive appraisals, creating and perpetuating stereotypes. The process can be understood with reference to evolutionary theory and the avoidance of situations which threaten survival of the group. These processes have an aversive impact on those labelled as mentally ill, especially on the basis of self-fulfilling prophecy and labelling theory.

Many research projects have explored the emotional effect of social exclusion. As stigma is a catalyst for social exclusion, the impact upon psychological functioning is notable. Not only does it increase stress and psychological symptoms, it can lead to negative affect, impacting upon self-esteem and reinforcing the cycle.

Self-esteem develops throughout life, but challenges and damage to a person’s self-view can increase anxiety levels (Sowislo & Orth, 2013). Those who are stigmatised and socially excluded because of mental illness may experience reduced self-esteem and deteriorating psychological state. A study by Corrigan & Penn, (2015) found that 75% of respondents to a survey, stated that stigma reduced their child’s self-esteem. This poignant statistic, expresses the widespread impact of stigma on developing self-esteem. It may also lead to issues into adulthood, especially concerning self-schemas and internal appraisals.

As self-esteem and self-schemas are so closely related, damaging one can lead to damaging the other. Social exclusion as a result of stigmatisation not only impacts upon an individual’s self-esteem but also changes their internal view of both themselves and the world. This can be damaging for psychological well-being and function (Corrigan, Watson & Barr, 2006).

Corrigan & Penn, (2015) stated that the impact of stigma may be as harmful as the disease itself and that significant emotional harm is not limited to the individual but also extends to their family and friends. This may be partially due to the social impact of the difficulties associated with supporting someone who has to cope with these injustices.

The emotional effect of stigmatisation is further demonstrated in research conducted into the help seeking behaviours of men in the military (Heath et al., 2017). They found that men typically sought help only when the perceived severity of the condition and distress levels are high. Limited social support may contribute to the lower levels of help seeking (Vogel et at., 2014) as may stereotypes surrounding male physical and psychological toughness. Furthermore, as help-seeking behaviours may challenge the norms of male, military behaviour, they may elicit aversive psychological states and contradictory self-schemas, threatening self-concept and psychological well-being. These factors are reflected in the high incidence of severe mental illnesses in the military and the male populations.

Interestingly, a study comparing the typically masculine disorders such as antisocial personality disorder and pyromania, against typically feminine disorders such as Bulimia, found typically masculine disorders were associated with more stigma than typically feminine disorders (Boysen & Logan, 2017). Gender roles and standards can impact on how mental disorders are perceived and the importance of accepted norms in our society which create and perpetuate stigma.

Obesity


Obesity is categorised by the World Health Organisation as ‘''…excessive fat accumulation that may impair health. Body mass index (BMI)…is commonly used to classify overweight and obesity in adults''’ ("Obesity and overweight", 2017). Obesity can cause many health problems and is a risk factor in Coronary Heart Disease. It is not, however, only the physical health risks which are of concern; obesity has been linked to many mental health disorders, including anxiety and depression.

History
Obesity is a relatively new concept. Its origins involve the combination of confounding factors which have developed in more recent decades. Industrialisation has led to technological advancements which have changed the amount and types of foods available as well as patterns of day-to-day, physical activity. However, our physiology has not adapted at the same rate to compensate for these changes. Our bodies were designed to store food for as long as possible to prevent starvation. However, with the accessibility of both healthy and unhealthy foods, along with a decrease in activity, obesity rates are increasing. Stigma associated with obesity, relates to body image norms, which vary cross-culturally and throughout time. The media strongly impacts upon what is considered to be the norm, and has the power to reduce weight related stigma (Bellisari, 2008).

Emotional effect
Theoretically, the stigmatisation and social exclusion of obese individuals derives from social norms around attractiveness and stereotypical characterisations of laziness. A study by Wang et al. (2004) stated that over-weight and obese participants internalise social stigma leading to more negative associations about being overweight. Participants from the study explicitly stated that ‘fat people are lazier than thin people. Stigma impacts upon self-schemas and internalised labels. Individuals who have been exposed to excessive stereotypes regarding their appearance and this has led to a change in cognitive appraisal concerning their own behaviour, which in most cases is incorrect.

The study, (Smart Richman & Leary, 2009) reported that long-term exposure to negative interpersonal reactions lead to both psychological difficulties and poor health. As a result, obese individuals who are subjected to stigmatisation are more likely to have poor health due to the physiological and psychological impacts.

Physiological origins were long thought to be the sole cause of obesity. However, Muennig, (2008) found that obesity and stress are related to the same diseases such as sleep apnoea and concluded that obesity aetiology is a combination of physiological and stress related reactions. This reinforces a cyclical process whereby the physiological and psychological mechanisms causing obesity lead to stigmatisation and social exclusion. The associated increase in stress levels, impact physiological mechanisms and continue the existing behaviours which are linked with obesity.

A study by Doll et al., (2000) observed the effect of obesity on emotional and physical well-being. While they found no direct relationship between obesity and poor emotional well-being, the results showed that there was a connection between obesity and poor physical well-being. This may have indirect negative, emotional consequences as poor physical well-being has been linked to increased stress and worry. (Fox, 1999)

In accordance with the theory of Social identity, individuals strive to belong as part of a group. However, those who do not meet the "ideal" body type are commonly assigned to the "out-group". The significance of this can be noted as Muennig (2008) found that body image norms may be linked to the cause of obesity, reinforcing the idea that an internalised concept of the ‘ideal body’ combined with social stigma can be detrimental to both physical and mental health.

Furthermore, Vartanian et al., (2016) reported that obese individuals were exposed to weight related stigma at least once every day, leading to a decline in positive affect, impacting on mood and decreasing motivation levels for that day. This may relate to the theoretical constructs of cognitive appraisals, with limited coping abilities potentially causing this decrease in motivation.

Schwarzer & Weiner, (1991) proposed that the extent of social support and the emotional reactions towards those being stigmatised, depended upon the perceived controllability of their ailment. Anger and limited support was directed at overweight and obese individuals who were perceived to be responsible for their weight.

Nestler & Egloff, (2013) also found a connection between stigma and perceptions of personal control. Discrimination targeted towards obesity had a significant impact upon self-esteem. This may be explained by Lazarus’ theory of cognitive appraisals, regarding the ability to cope with external events. Their results indicated that failed weight-loss attempts impact on both the individual and the whole group, as failure is appraised as confirmation of the stereotypic label ‘lazy’ (Wang, Brownell & Wadden, 2004). According to labelling theory, this is internalised and becomes part of the cognitions regarding the self.

In some cases, the impact of social exclusion is reduced as members of the "out-group" form  connections, increasing the feeling of belonging and potentially mitigating some emotional responses to social exclusion. However, Wang et al., (2004) found that this is not the case for over-weight and obese individuals, who do not establish connections with others sharing these characteristics. This is detrimental for those facing the exclusion and for the possibility of diminishing the stigma.

These studies have emphasised the significance of the negative consequences of stigmatisation on mood, motivation and self-esteem. While these are only some aspects of emotion, it can be noted that they would contribute to other negative emotional responses, such as anger and sadness. Thus, continued exposure to stigma links to negative emotions and may lead to the development or perpetuation of mental illnesses.

Reducing Stigma
As discussed, the process of stigmatisation can have harmful effects upon those who are subject to it strategies need to be implemented to reduce the incidence and mitigate its effects.

The most effective strategy for reducing stigma was described by Corrigan & Penn, (2015) who argue the need to instigate change towards ‘poorly justified knowledge structures’ by way of Protest, Education and Contact. Each step is designed to challenge stereotypical concepts surrounding stigmatised populations.

To deal with stigma on an individual level, there needs to be methodologies available which can evaluate internalised stigma. These may be useful in evaluating the extent to which internal appraisals, schemas, and self-concepts are effected. The Internalised Stigma of Mental Illness (ISMI) is a good example of one of these tests (Boyd Ritsher, Otilingam & Grajales, 2003).

Another encouraging finding in relation to stigma is that while many studies have expressed the negative emotional impact, DeWall et al., (2011) found that acute social exclusion can in particular cases, activate regulated positive emotional responses. Findings suggest that ostracism over a short period of time encourages strong emotional responses, and thus increases coping capabilities, resulting from adaptive emotional responses. While this may not be true for those who experience stigmatisation constantly, there is hope that more research will provide insight into internal responses; improving and expanding possible coping strategies.

Conclusion
Stigma is a common element of social interaction. Theoretical conceptualisations direct their focus towards the social and neurological reasoning behind this phenomena. However, these theories fail to give insight into how this process can be stopped or prevented. This is vital as the impacts of stigmatisation have been shown to be at the root of many issues in society today on both macro and micro levels. While the emotional effect varies interpersonally, overall it has been shown to increase the incidence of negative affect and reduce self-esteem. Further research into the emotional complexities and impact of stigmatisation, may begin to provide insight into strategies which can reduce, negate or even prevent it.